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Endoscopic Vesicoureteral Reflux Treatment Outcomes in Patients ISSN: 2469-5742 Kırlı et al. Int Arch Urol Complic 2019, 5:052 DOI: 10.23937/2469-5742/1510052 Volume 5 | Issue 1 International Archives of Open Access Urology and Complications REsEARcH ARTiclE Endoscopic Vesicoureteral Reflux Treatment Outcomes in Patients with Voiding Dysfunction Elif Altınay Kırlı, Çağatay Doğan, Mehmet Hamza Gültekin, Zübeyr Talat and Bülent Önal* Istanbul University–Cerrahpaşa Cerrahpaşa School of Medicine, Departmant of Urology, Turkey *Corresponding author: Bülent Önal, MD, Professor, Department of Urology, Cerrahpaşa Faculty of Check for Medicine, Istanbul University, Turkey, Tel: +90-543-7955564; +90-212-4143000/21200 updates Abstract Introduction Objective: Voiding dysfunction (VD) increases the Vesicoureteral reflux (VUR) is the most frequent frequency of vesicoureteral reflux (VUR). Subureteric urinary system anomaly of the pediatric population injection is an effective method for the treatment; however, with 1% incidence [1,2]. The main etiological cause is the presence of VD may affect the success rates. This study evaluated the results of single-session endoscopic the anatomically inadequate anti-reflux mechanism. treatment in patients admitting with VD symptoms who were Non-neuropathic lower urinary tract dysfunction diagnosed with VUR, and the effect of compliance to VD treatment on these results. (LUTD) is based purely on the fact that any neurologic lesions that can affect the lower urinary system can Materials and method: The data regarding patients who be identified [3]. In patients who also have voiding were being followed up for non-neurogenic VD diagnosis and who underwent subureteric injection or treated dysfunction (VD), especially who have impaired bladder conservatively was reviewed retrospectively in terms of compliance; VUR may develop due to impaired bladder follow up information and surgical outcomes. Endoscopic dynamic [4-6]. treatment was performed by applying dextranomer/ hyaluronic acid copolymer via submucosal route. Filling-phase and voiding phase dysfunctions are the Symptomatic and radiological assessments of the patients two main groups of LUTD. Detrusor can be over active on month 3 were reviewed. (DOA) as in over active bladder (OAB) or underactive Results: The data of 45 patients (67 renal unites (RU)) as in underactive bladder. Detrusor underactivity were assessed. 24 of them treated conservatively 21 of (DUA) denotes voiding contraction of reduced strength them underwent endoscopic subureteric injection (STING). resulting prolonged bladder emptying or failure to STING was performed for Grade 1 VUR in 3 RU, grade 2 in 12 RU, grade 3 in 16 RU, grade 4 in 2 RU, and grade 5 in 2 achieve complete emptying. Habitual postponing the RU. The success rate after subureteric injection treatment micturition is also in this group. Detrusor-sphincter was found to be 68%. VD treatment incompliance rate was interference is the main problem of voiding phase. This detected to be 31%, and infection rate during follow-up after condition can be a transitional phases of a complex injection to be 24%. sequence due to fact that should not be viewed as Conclusion: Providing regular treatment for voiding distinct entities [3,7,8]. dysfunction for at least 6 months before the endoscopic injection treatment for VUR accompanied by VD is The common problem in patients with VUR and important for increasing the success rates. That being said, VD is the renal injury developed as a result of urinary the success rate in this group might be lower than expected tract infections (UTIs) [9]. The coexistence of two pa- despite proper treatment for bladder. thologies may cause increase in the risk of renal failure. Keywords Therefore, VD investigation is an important part of the Vesicoureteral reflux, Voiding dysfunction, Subureteric diagnosis process in children diagnosed with VUR. injection Citation: Kırlı EA, Doğan C, Gültekin MH, Talat Z, Önal B (2019) Endoscopic Vesicoureteral Re- flux Treatment Outcomes in Patients with Voiding Dysfunction. Int Arch Urol Complic 5:052. doi. org/10.23937/2469-5742/1510052 Accepted: January 26, 2019: Published: January 28, 2019 Copyright: © 2019 Kırlı EA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Kırlı et al. Int Arch Urol Complic 2019, 5:052 • Page 1 of 5 • DOI: 10.23937/2469-5742/1510052 ISSN: 2469-5742 Spontaneous resolution may occur in low-grade urinary tract, abdominal and pelvic muscles), habitual VUR especially detected in early childhood. That being regulations as fluid intake, regular voiding and dietary said, in cases in which urinary tract infection cannot be regulation for preventing constipation. Optimal void- controlled and scarring occurs, the preferred treatment ing position was demonstrated with the child in front is surgery irrespective of VUR grade [1]. Endoscopic of a mirror. Micturition was supervised and corrections subureteric injection (STING) in VUR treatment is a made until achieving patient’s cooperation [8]. minimally invasive and well-tolerated method, which In addition to standard urotherapy, antibiotherapy provides a cure rate similar to open surgery. Today, was initiated at suppressive dose in patients with UTI it is preferred as primary surgical approach for VUR that was proved by urinary culture (trimethoprim (1-2 [10-12]. Also, endoscopic approach in the patients mg/kg)- Sulfamethoxazole (10-15 mg/kg) or nitrofuran- with neuropathic bladder who may also have many toin (1 mg/kg) according to urinary culture features), comorbidities has been described as a preferable and laxative treatment was initiated for patients with method compared to open surgical approaches [10-13]. the complaint of constipation. The continuity of anti- This study mainly evaluated the efficacy of single- muscarinic treatment, antibiotic suppression and stan- session STING in a patient group detected to have dard urotherapy for 6 months was accepted as compli- coexisting VD and VUR, and the effect of compliance ance to medical treatment. to VD treatment on success rates. Also provides information about the follow-up of patients followed by Dimercaptosuccinic acid static scintigraphy (DMSA) conservatively. scanning was performed as a initial scan for renal function and scarring. Additionally, in the case of Materials and Method recurrent UTI or pyelonephritis under the antibiotic Medical records of 150 patients (216 renal unit suppression is the other indication of DMSA scans for (RU)) who diagnosed as VUR in the past 10 years were evaluating new scar formation. evaluated retrospectively. Patients who were treated STING was performed in all RU that require surgical due to VUR accompanied by VD and evaluated with management. STING indication for low-grade reflux DMSA and voiding cystourethrography examination at is UTI persisting under suppressive therapy and the the time of diagnosis and at least one VCUG examination detection of scarring in dimercaptosuccinic acid static during follow-up or post-operative period were accepted scintigraphy (DMSA) in renal unit (RU) at the time of to study. 67 RU of a total of 45 patients with complete diagnosis. medical records, were assessed retrospectively for affect of medical treatment and urotherapy compliance Single-session subureteric injection treatment is per- on clinical findings and follow up period characteristics. formed by applying classic STING technique, which was described by O’Donnell and Puri. Zero lens cystoscope VUR grades were assessed radiologically by was used to identify ureterovesical junction (UVJ) and performing voiding cystourethrography before and 5Fr needle was inserted at 6 o’clock position. After en- after treatment [14]. All patients were assessed for tering the mucosa 2-3 mm distal to UVJ, needle was ad- VD before the endoscopic intervention using voiding vanced to submucosal plane for a distance of 4-5 mm. diary and if clinically indicated, urodynamics. Voiding An average of 0.5 cc of Dextranomer/hyaluronic acid dysfunction symptom score was used for quantitative copolymer injection was performed until the mound systematic review of the voiding symptoms and also becomes apparent [16]. used for follow-up [15]. Follow-up for the patients after the procedure was DUA diagnoses were made using urodynamics, and performed with routine outpatient clinic visits, and OAB diagnosis based on symptoms and urodynamics radiologically, using USG at month 1, and USG and findings. Oxybutynin (0.1-0.3 mg/kg, 3 times daily) VCUG at month 6. Complete regression or downgrading was initiated for antimuscarinic treatment in patients of reflux in VCUG was considered as success and diagnosed with DOA or OAB. persisting or increasing reflux grade during follow-up Post-void residual urine was evaluated according was considered as failure. Statistical evaluation was to age-based criteria of International Children’s Con- performed using Wilcoxon Signed Rank test. tinence Society and clean intermittent catheterization Results was recommended in DUA patients with post-void re- sidual urine [8]. Patients were assessed for constipation 67 RU belong to forty-five patients (34 females, 11 and urinary tract infection in their initial and follow-up males) were evaluated. Twenty-four patients (32 RU) visits. were treated conservatively and 21 patients (35 RU) had STING procedure. All patients were introduced for standard urothera-
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